Simply put, an impulse is an urge to initiate an action. You may have experienced the urge to slam a door aggressively on having an argument with a loved one or to purchase a product because there was a massive discount on it. While these are day to day impulsive actions, an impulse control disorder is a far more serious condition, in which a child you may repeatedly give in to a particular impulse, often leading to serious and harmful consequences. You may find doing the act pleasurable or gratifying, but experience guilt, remorse or shame after you have acted. Because of the shame you experience on failing to resist the impulse, you may feel obliged to keep this behaviour a secret.
Impulse control disorders are characterised by three aspects:
inability to resist acting on an impulse even thought it leads to negative consequences,
Mounting anxiety prior to initiating the action (thus making the impulse irresistible), and
Relief or gratification while performing the action. While responding to the impulse, you may feel like you temporarily lose the ability to rationally make a decision.
These disorders generally co-occur with anxiety, depressive, substance use disorders, certain personality disorders and conduct related disorders. In general, these disorders initially begin in childhood or adolescence. Impulse control disorders such as Intermittent Explosive Disorder and Pyromania are more common in men than women whereas Kleptomania and Trichotillomania are more common in women.
CAUSES
Impulse Control Disorders have their roots in biological, psychological, as well as social well-being of a person. As such, no one specific cause can be implicated in the development of an Impulse control disorder.
Psychological theories: The specific cause of Impulse Control Disorders is not yet known. However, constant stress, excessive exposure to stimulation and trauma are often linked with a decreased ability to resist an impulse. Thus, childhood exposure to abusive environment, antisocial behaviour and alcohol abuse is linked with higher risk of developing an impulse control disorder.
Individuals with a high need for sensation seeking seem to be more prone to developing an impulse control disorder.
Brain systems: Impulse control problems, particularly those associated with violence and aggressive behaviour have been found to have an association with the limbic system in the brain. This system is related to emotional responses such as fear, pleasure, anger and sexual arousal. Additionally, the neurotransmitters (brain chemicals) associated with addictive behaviours such as serotonin and dopamine have been implicated in several studies of Impulse Control Disorders as well.
Types Of Impulse Control Disorders:
Kleptomania
Kleptomania is a disorder in which an individual experiences repeated urges to steal items of very little value. If you feel that any of the symptoms given below pertain to you, it is advisable that you speak to the doctor about your concerns.
- Difficulty in resisting a repeated, overwhelming urge to steal
- Immediately prior to stealing, you experience intense anxiety
- While stealing, you experience pleasure, relief or gratification
- Urge to steal is not out of revenge, anger, or for personal or monetary use
- It is also not in response to any hallucinations or delusions
It is a common myth that a person with kleptomania steals because he or she wants to own or possess the item of theft. Unlike thieves, those suffering from Kleptomania often steal items of little value or use to them and they may even give away, discard or sneakily give back the items stolen. The stealing is in response to the urge to steal, not with a goal of monetary profit, and many a times, the individuals can afford the items stolen. They are aware that the act is senseless and inappropriate, and could possibly lead to negative consequences. While they may feel pleasure during the act of stealing, they may experience guilt or shame later. Owing to the fact that the individuals steal because they find it difficult to resist the temptation, such acts are usually unplanned.
This disorder is thrice as common in women as in men, and generally begins in adolescence. However, it could also develop in childhood or young adulthood.
Kleptomania commonly occurs together with bulimia nervosa and some personality disorders. First degree relatives of those with Kleptomania are generally seen to have higher number of cases of Obsessive Compulsive Disorder or depressive disorders.
Trichotillomania
Trichotillomania is an impulsive pulling of one’s hair, usually from the scalp, eyebrows or eyelashes. It may also involve other areas, such as armpits and pubic hair. For some individuals, this may be an automatic action while for some others, it may be intentional. In many cases, there is an increasing tension prior to hair-pulling, and pleasure while pulling out hair. This behaviour is also seen in children, but is usually less serious. Your hair may appear as short broken strands among long strands or patches of thinned out or lost hair, thus causing embarrassment and affecting your social life. While you may not engage in hair pulling around other people, you may feel the urge to pull out hairs from others as well.
You may tend to ‘play’ with the pulled out hair, rolling it between fingers, biting it or even swallowing it. The inability to stop this behaviour, along with the shame may lead you to lie about this behaviour. Initially, it may have begun as a response to some stress, but soon taking over a compulsive quality.
This disorder is often found along with Obsessive Compulsive Disorder, and is thought to have a biological link to such disorders.
Intermittent Explosive Disorder
This disorder is characterised by a failure to resist an impulsive aggressive outburst, leading to destruction of properly and/or physical assault. You may feel extremely angry at little provocation, and find it very difficult to control verbal or physical aggression. You may lose control over your aggressiveness as often as twice in one week. It is a sudden rage, in that; it is not pre-planned, in order to achieve some goal.
Owing to the angry outbursts, you may experience problems in your relationships, work, as well as social life. In addition, the destruction of property may take a toll on your finances as well.
In addition to the depressive, anxiety and substance disorders that are commonly associated with Impulse control disorders, this order is also linked with antisocial or borderline personality disorders and behavioural disorders like conduct disorder and ADHD. Unlike this disorder, most of the above mentioned disorders generally begin at a much later stage. A child of as young as 7 years old could have an intermittent explosive disorder, as this disorder generally begins in childhood or adolescence.
Research on this disorder suggests that having a family member who suffers from the disorder greatly increases the likelihood of an individual developing this disorder. A brain region known as amygdala, which is associated with emotions shows a heightened response to anger stimuli in such individuals. Additionally, early life traumas as well as later loss of close friend or family could contribute to an individual developing this disorder.
Pyromania
Pyromania is a disorder in which an individual knowingly sets up a fire on more than one occasion, with no regard for destruction of property or sometimes, even loss of life. The fire setting is not due to a political motive, or an act of vengeance, or to improve one’s life conditions or out of impairment in judgement. Like in other impulse control disorders, you may experience an increasing anxiety prior to seeing up the fire, and relief or pleasure while setting it up or witnessing it. You experience a fascination to fire and aspects related to it, such as fire-fighters, and may want to take up work as one. You may have often stopped to watch fires, or set off fire alarms.
Many individuals suffering from pyromania have been found to have a present or past history of alcohol abuse. Along with the co-occurring disorders mentioned in the beginning, such individuals may show a tendency to run away from home, engage in delinquent behaviours as well as cruelty to animals. Mild intellectual deficits and a history of bedwetting behaviour have also been noted with several cases of pyromania.
Treatment
Individuals with disorders such as Kleptomania and Pyromania rarely come to seek help with these disorders as primary concern. Instead, the disorder is detected while in treatment for other conditions such as depressive or anxiety disorders. There is also a difference in how soon men and women seek help for such disorders, with women typically approaching much sooner than men. Treatment of impulse control disorders involves a combined approach of medication and therapy. Medication is aimed at re-establishing the balance of the neurotransmitters (brain chemicals) to reduce symptoms and therapy focuses on the thoughts, behaviours, emotions and lifestyle patterns that may be contributing to the inability to control the impulsive behaviours.
Medication
Medications such as fluoxetine, fluvoxamine, lithium, valproate, trazadone and natrexone have shown promise in treating kleptomania.
The treatment of trichotillomania can involve medications such as antidepressants, anxiolytics as well as serotonergic agents. Medications that have been found to be effective include naltrexone, trazodone, buspirone and clonazepam.
Medications used to treat intermittent explosive disorder may include anticonvulsants, anti-psychotics as well as selective serotonin reuptake inhibitors. Specifically, lithium, valproate, divalproex, trazodone and buspirone have shown efficacy in treating this disorder.
Therapy
Therapeutic techniques such as Behaviour Therapy, Family Therapy, Insight Oriented Psychotherapy as well as Group Therapy have shown promise with Impulse Control Disorders.
Insight Oriented psychotherapy: In impulse control disorders such as kleptomania, the individuals are often motivated to change because of the guilt and shame they experience after engaging in the behaviour. In such cases, insight oriented therapy has been proved to be quite effective.
Group therapy: In a group therapy setup, individuals with similar concerns are carefully selected so as to foster an environment of change. Under the guidance of a trained mental health professional, experiences such as coming in contact with individuals who face the same concerns, learning coping mechanisms through other’s experiences and getting immediate feedback, individuals can get help in recovering from Impulse Control Disorders Behaviour therapy: Behaviour therapy techniques such as covert sensitization, systematic desensitization, aversive conditioning has been proved to be effective in cases of kleptomania and trichotillomania, even in cases with low motivation.
Covert Sensitization: This is a technique in which an individual is asked to bring up images of undesirable things (for example, vomit) when they feel the urge to engage in impulsive behaviour (for example, stealing).
Along with behaviour therapy methods mentioned above, treatment of Trichotillomania may involve methods such as bio-feedback, self-monitoring, as well as hypnotherapy. Trichotillomania in children is easier to treat, with behaviour therapy being the most effective treatment. Family Therapy: Family therapy is often necessary in case of Impulse Control Disorders to help family members understand the disorder and its impact on the individual. When family members understand that the behaviour that the individual is engaging in is due to the disorder, and extend their support to the individual, recovery is aided to a great extent. Additionally, family patterns and styles of interaction among the family members that may be contributing to the disorder can come to light and worked upon.
For treatment of intermittent explosive disorder, family therapy and group psychotherapy have been found to be more effective than individual psychotherapy. The goal of the therapy would be to enable the individual to verbalise thoughts and feelings instead of acting upon them in an aggressive manner. For Pyromania, especially in adolescents, family therapy and behaviour therapy are key aspects of treatment. In some cases, constant supervision may be required to ensure no new instances of fire-setting take place. In children, it is crucial to monitor fire setting behaviours, as a majority of fire-setting incidents (not specifically pyromania) happen prior to young adulthood.
Thus, several treatment approaches have been found to be effective, with several new methods emerging with increasing research.
If you believe; you or a loved one have an impulse control disorder, and are ashamed or afraid to seek help, it is important to know that treatment is available and effective, thereby enabling you to lead a guilt or shame free life. Using a combination of medication, therapy, support from family and friends, as well as changes in life patterns, individuals with Impulse Control Disorders can live happy and fulfilling lives.
We at Mumbai Psychiatry Clinics have a dedicated team of counsellors and clinical psychologists who will help you with your problems, cite interventions and assess the progress on regular intervals. There are experienced psychiatrists who will be guiding you throughout your journey and our Multidisciplinary team will try to assure you with the best help possible.
Reference
- Kaplan
- DSM
- Abnormal Psychology – Richard Halgin, Whitbourne
- Abnormal Psychology – Barlow